NCC223461_FRO Submitted_20221010

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROI.INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name WAKE CHRISTIAN ACADEMY PARKING LOT EXPANSION
2. Location of land -disturbing activity: Jurisdiction Wake Count (Wake Co. or Municipality)
Highway/Street 5500 Wake Academy Dr. Latitude 35.705015 Longitude-78.670652
3. Approximate date land -disturbing activity will commence: May 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 3.7 AC.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Woods
Telephone_(919) 334-0974
E-mail Address mikewoods wakechristianacadem .com
Cell # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake Christian Academy. Inc.
Name(s)
5500 Wake Academy Drive
Current Mailing Address
Raleigh NC 27603
City State Zip
8. Deed Book No. Page No.
Part B.
[phone]
Telephone
5500 Wake Academy Drive
Current Street Address
Fax # N/A
N/A
Fax or E-mail address
Raleigh NC 27603
City State Zip
Provide a copy of the most current deed.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Mike Woods _
Name
5500 Wake Academy Drive
Current Mailing Address
Raleiah NC 27603
City State Zip
mikewoodsLn].wakechristianacademy.com
E-mail Address
5500 Wake Academy D
Current Street Address
Raleiq!l NC 27603
City State Zip
Telephone -.919, 334-0974 Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Mike Woods Head of School
Type or print name Title or Authority
aaaP2- _
Signature Date
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I'1 1 n(A� S , a Notary Public of the County of
State of North Carolina, hereby certify that OOt rape
personally before me this day and being duly sworn acknowledged that the above form was a eiA
Witness my hand and notarial seal, thisL_day of�_- q, 20 1 W
Seal
Notary
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CouN`�
My commission expires (P LIP i Lo—a-i
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